BMJ  2004;328:794 (3 April), doi:10.1136/bmj.328.7443.794

Paper

Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic review

¹ Royal London Hospital (St Clement's), London E3 4LL, ² WHO Collaborating Centre for Mental Health, Institute of Psychiatry, London SE5 8AF

Abstract

Objectives To assess the available evidence on the prevalence, aetiology, treatment, and prevention of anxiety and depressive disorders in Pakistan.

Design Systematic review of published literature.

Studies reviewed 20 studies, of which 17 gave prevalence estimates and 11 discussed risk factors.

Main outcome measures Prevalence of anxiety and depressive disorders, risk factors, effects of treatment.

Results Factors positively associated with anxiety and depressive disorders were female sex, middle age, low level of education, financial difficulty, being a housewife, and relationship problems. Arguments with husbands and relational problems with in-laws were positively associated in 3/11 studies. Those who had close confiding relationships were less likely to have anxiety and depressive disorders. Mean overall prevalence of anxiety and depressive disorders in the community population was 34% (range 29-66% for women and 10-33% for men). There were no rigorously controlled trials of treatments for these disorders.

Conclusions Available evidence suggests a major social cause for anxiety and depressive disorders in Pakistan. This evidence is limited because of methodological problems, so caution must be exercised in generalising this to the whole of the population of Pakistan.

Introduction

Anxiety and depressive disorders constitute a substantial proportion of the global burden of disease, and are projected to form the second most common cause of disability by 2020.¹ Non-communicable diseases such as these present a particular challenge for low income countries, where infectious diseases and malnutrition are still rife, and where only a low percentage of gross domestic product is allocated to health services.² These disorders are also important because of their economic consequences.³

With an estimated population of 152 million, Pakistan is the sixth most populous country in the world, and is projected to be the fourth most populous by 2050.⁴ There is a need to develop an evidence base to aid policy development on tackling anxiety and depressive disorders. We therefore conducted a systematic review as no such work existed to our knowledge.

Our main questions were (a) what the estimated prevalence of anxiety and depressive disorders is in Pakistan and how this compares with estimates from other low income countries; (b) what the associated social, psychological, and biological factors are; and (c) what evidence exists for effectiveness of treatment or prevention in this population.

Methods

Data sources
Using the key words "Pakistan" and ("mental" or "depression" or "anxiety" or "psychiatric"), we searched bibliographic databases, reference lists of retrieved articles, Pakmedinet.com, and the Pakistan Journal of Clinical Psychiatry until 1995, when it ceased publication. See bmj.com for details.

Study selection
We selected studies that were conducted within Pakistan and that focused on depression, depressive disorder, or anxiety disorder in adults (ages 18-65). We assessed the methodological quality of the selected studies, but since relatively few addressed our study questions, we included all studies directly relevant to the questions regardless of their quality. A narrative synthesis of the extracted studies was performed to address the questions of the review.

Results

We found 20 studies that directly addressed the questions of the review: 19 were cross sectional epidemiological surveys, and one was a case-control study.^w1-w20 Seventeen gave prevalence estimates (n = 9170), while 11 discussed associated risk factors. We did not find any prospective study of the natural course of the disorder or a rigorously controlled study of any interventions. We found little qualitative work. Sample sizes ranged from 113 to 2620 in prevalence studies (mean 539.41, median 298).

Methods of included studies
Only three of the 11 prevalence studies published in local journals gave adequate details of methods. Because of this, it is difficult to comment on possible biases. Diagnoses in all the studies were made by either a psychiatrist or a trained worker using a validated instrument, and thus seem to be of reasonably good quality.

Most of the studies discussed the generalisability of their findings but did not interpret any null findings. In the discussions, national comparisons were rarely made with findings of other national research groups; comparisons were usually with studies in other countries.

Prevalence of anxiety and depressive disorders
The overall mean prevalence in men and women in the six studies of random community samples (n = 2658) was 33.62%, with the point prevalence varying from 28.8% to 66% for women (overall mean 45.5%) and from 10% to 33% for men (overall mean 21.7%). Women aged 15-49 were studied in a paper with 28.8% prevalence, while young men with a mean age of 18 participated in a study reporting 33% prevalence. Only one study reported adjusted prevalence with 95% confidence intervals.

For those presenting to traditional or faith healers (n = 511), the prevalence of anxiety and depressive disorders among men varied from 2.65% to 27%, and among women from 11.5 % to 52%.

Three studies looked at total psychiatric morbidity in primary care (n = 774). One described women in a rural area, with a prevalence of 50%, while another described 18% prevalence for men and 42.2% for women in an urban area. The third study, with a prevalence of 38.4%, did not specify participants' sex.

Of those presenting to psychiatric outpatients (n = 2430), the prevalence varied between 32% and 66.3%. There were two studies on psychiatric inpatients, one reported a prevalence of depressive illness of 37% (n = 2620), while the other reported 19.1% (n = 177).

Associated social, psychological, and biological factors
The table shows the various factors found to be associated with anxiety and depressive disorders. Increased prevalence was associated with female sex, middle age, low level of education, difficulties with finances, being a housewife and relationship problems.

View this table: [in this window] [in a new window]   Factors associated with risk of anxiety and depressive disorders in studies included in systematic review

 

What is the evidence for effectiveness of treatment or prevention in this population?
We could not find any prospective study of the natural course of the disorder or any rigorous controlled study addressing effectiveness of treatment and prevention. We found only one randomised controlled trial in mental health, regarding the ability of schoolchildren to detect mental disorders after having been given health education.⁵

Discussion

In our systematic review we found that socioeconomic adversity and relationship problems were major risk factors for anxiety and depressive disorders in Pakistan, whereas supportive family and friends may protect against development of these disorders.

Limitations of study
Our review may be subject to publication and selection bias as we were unable to systematically contact the experts in Pakistan for unpublished material or grey literature.

The coverage of the studies we identified is low. Most studies satisfying our inclusion criteria were from the provinces of Punjab and Sindh, the two provinces with the largest population. The epidemiological data were collected from a handful of villages and urban settlements. There was considerable methodological variation in study design and in the instruments used. Thus one is unable to extrapolate these epidemiological findings to the whole of Pakistan.

Comparison with other low income countries
Using stringent criteria, Harding et al reported an overall frequency of anxiety and depression of 13.9% in four developing countries.⁶ Community studies from Africa have reported prevalences of 24% in rural Uganda and 20%-24% in rural South Africa. Among patients attending primary care, the prevalence varied from 8% to 29%. Patients attending primary care in India showed prevalences between 21% and 57%.⁷

What is already known on this subject Anxiety and depressive disorders are associated with considerable economic burden These disorders represent an emerging public health threat in low income countries What this study adds In Pakistan relationship problems, financial difficulties, and low educational level are positively associated with anxiety and depressive disorders, whereas having a supportive relationship is negatively associated Systematically collected, peer reviewed evidence suggests an overall prevalence of 34% for anxiety and depressive disorders in this population, but this finding must be treated with caution because of methodological limitations Nationally representative psychiatric morbidity surveys and controlled treatment trials are needed to inform policy in order to control morbidity from anxiety and depressive disorders in Pakistan

In relation to risk factors, Abas and Broadhead found a significant association with formal employment, below average income, overcrowding, and certificate of secondary education in urban Zimbabwe.⁸ In the same study, they also found a significant association with humiliation or entrapment and with death or other loss.⁹ Bhagwanjee in rural South Africa found similar risk factors to those from Pakistan.¹⁰ However, we found that the reported overall rates were higher in Pakistan and higher among rural than urban populations compared with the above studies. The question is whether these differences are an artefact of measurement or are because of specific factors operating in Pakistan.

Pakistan's population has been exposed to sociopolitical instability, economic uncertainty, violence, regional conflict, and dislocation for at least the past three decades.¹¹ These are risk factors for psychiatric disorders² and may help explain the findings of this review.

The need for stronger evidence and improved research capacity
A coherent mental health policy with a strategic implementation plan is essential for countries that wish to enhance their social, economic, and social capital.¹²

A major obstacle in formulating effective health policy is the lack of robust epidemiological research in Pakistan.¹³ The time is right for Pakistan to build on this research effort, increase investment in research capacity and develop a national epidemiological survey of mental disorders.

Conclusion
Available evidence suggests a major social cause for anxiety and depressive disorders in Pakistan, and an overall prevalence of 34%. This evidence is limited because of methodological problems. Nationally representative psychiatric morbidity surveys and controlled treatment trials are required to inform policy in order to control morbidity from anxiety and depressive disorders.

---

References w1-w20 are listed on bmj.com

This is the abridged version of an article that appears on bmj.com

Contributors: See bmj.com

Funding: None.

Competing interests: None declared.

Ethical approval: Not required.

References

1. Murray C, Lopez A. The global burden of diseases: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Boston: Harvard School of Public Health, WHO and World Bank, 1996.
2. World Health Organization. Macroeconomics and health: investing in health for economic development. Geneva: WHO, 2001 (http://www3.who.int/whosis/menu.cfm?path=whosis,cmh&language=english).
3. Desjarlis R, Eisenberg L, Good B, Kleinman A. World mental health: problems and priorities in low-income countries. Oxford: Oxford University Press, 1995.
4. Population Division, Department of Economic and Social Affairs, United Nations Secretariat. U.N. The world at six billion (ESA/P/WP.154). Part 2—Table 5-8. New York: UN, 1999: 12-22. (www.un.org/esa/population/publications/sixbillion/sixbilpart2.pdf)
5. Rahman A, Mubbashar M, Gater R, Goldberg D. Randomised trial of impact of school mental-health programme in rural Rawalpindi, Pakistan. Lancet 1998;352: 1022-5.[CrossRef][Web of Science][Medline]
6. Harding TW, de Arango MV, Baltazar J, Climent CE, Ibrahim HH, Ladrido-Ignacio L, et al. Mental disorders in primary health care: a study of their frequency and diagnosis in four developing countries. Psychol Med 1980;10: 231-41.[Web of Science][Medline]
7. Institute of Medicine. Neurological, psychiatric, and developmental disorders: meeting the challenge in the developing world. Washington, DC: National Academy Press, 2001. (http://books.nap.edu/catalog/10111.html)
8. Abas M, Broadhead J. Depression and anxiety among women in an urban setting in Zimbabwe. Psychol Med 1997;27: 59-71.[CrossRef][Web of Science][Medline]
9. Broadhead J, Abas M. Life events, difficulties and depression among women in an urban setting in Zimbabwe. Psychol Med 1998;28: 29-38.[CrossRef][Web of Science][Medline]
10. Bhagwanjee A, Parekh A, Paruk Z, Petersen I, Subedar H. Prevalence of minor psychiatric disorders in an African rural community in South Africa. Psychol Med 1998;28: 1137-47.[CrossRef][Web of Science][Medline]
11. Mehmood S. Pakistan: political roots and development 1947-1999. Oxford: Oxford University Press, 2000.
12. Jenkins R. Making psychiatric epidemiology useful: the contribution of epidemiology to government policy. Acta Psychiatr Scand 2001;103: 2-14.[CrossRef][Medline]
13. Baig L. Why epidemiological research in Pakistan? J Pak Med Assn 2001;51: 206.[Medline]

(Accepted 5 March 2004)

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